Aortic valve replacement or heart transplantation in patients with aortic stenosis and severe left ventricular dysfunction

Introduction: The decision to perform aortic valve replacement ( AVR ) or heart transplantation ( HTx ) for aortic stenosis ( AS ) with severe left ventricular dysfunction is difficult and may be affected by prior myocardial infarction ( MI ) and coronary artery disease ( CAD ). Methods: Patients who underwent AVR from 1988 to 2001 with left ventricular ejection fraction ( LVEF ) < 30% and severe AS ( aortic valve area [AVA] < 1.0 cm2; n = 51 ) were assessed for operative mortality, late survival, and predictors of outcome, and were compared with HTx. Subsequently, 131 patients with LVEF ≤35% who underwent AVR for critical AS ( AVA < 0.8 cm2 ) were evaluated. Results: In the first 51 patients, 3-year survival was 100% ± 0% with no CAD, and 45% ± 10% with CAD ( P < .05 ); 3-year survival was 88% ± 12% with no bypass, 73% ± 12% with one to two grafts, and 18% ± 11% with three grafts ( P < .01 ). Survival with HTx was 78% at 3 years. In the subsequent analysis of 131 patients, 90-day survivors were followed for a mean 4.6 ± 3.5 years. Advanced age ( P = .001 ) was the only predictor of long-term mortality. LVEF improved from 28.5% ± 5.2% before AVR to 45.4% ± 13.2% at 1-month postoperatively ( P < .0001 ). New York Heart Association ( NYHA ) class III/IV decreased from 94.2% pre-AVR to 12.8% at 1 year ( P < .0001 ). Predictors of LVEF recovery were no previous MI ( P = .007 ) and higher AS gradient ( P = .03 ). Conclusions: In severe AS and LVEF < 30% with no concomitant CAD or with CAD requiring one to two bypass grafts, AVR has a survival equal to or exceeding that of HTx. In patients with CAD requiring more than two bypass grafts, survival is significantly reduced, and HTx can be considered.